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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www sigov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: 9 iR 2.0 , <br /> <br />' r'9 hi-- A; Le_ led,c---4466r <br />Permit#- <br />14/P0011 1 9iiii <br />Inspection Date: <br />572 Viz- J <br />Parameter/Standard <br />/ <br />Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes' X No El NA LII <br />Casing extends at least 12" above grade Yes' 5T No NA I I <br />Casing extends at least 1" above pedestal Yes' g No I I NA <br />Free of cracks/contiguous with annular seal Yes rl No NA LIII <br />Graded to allow drainage away from casing Yes g , No NA LII <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes' No I I NA <br />Seal between all pipe columns and casing Yes-4 No I I NA LII <br />Sounding tube/air vents sealed properly Yes f No I I NA El <br />Chlorination port available and sealed properly Yes .71 No NA El <br />SAMPLE TAP AND BACKFLOW PREVENTION. <br />Non-threaded sample tap between well head and <br />check valve or within 3' of well head Yes El No NA NI <br />Adequately installed check valve or BFP device YesV No NA Lii <br />No cross connections (ex: chemical feeders <br />hooked to distribution systern/ag flood irrigation <br />from domestic supply) Yes LII No NA M <br />Air gap of at least 6" (same as pipe diameter) Yes No El NA IM <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes171 No n NA El <br />Well/Pump free from excessive vegetation Yes IY No NA El <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes R. No El <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes IYI No El <br />Photograph taken and attached to record Yes 14 No El <br />OTHER: <br />Comments: <br />()10 <br />Inspected By: D ,_„--- , 0....._ A-F,rt, 31eA)0,.._ Title: eff-ts <br />Received By: Date: S/2 Li /70z,I <br />EH-4200- 8/31/2015